Confidential | Copyright © 2014 TriZetto Corporation 1.

2 CAQH CORE Compatibility Solution Ron Gripon, Sue Massaro, Stephen Weir

Confidential | Copyright © 2014 TriZetto Corporation 4 About CAQH - Council for Affordable Quality Healthcare, Inc. (http://www.caqh.org/)http://www.caqh.org/  CAQH, an unprecedented nonprofit alliance of health plans and trade associations, is simplifying healthcare administration through industry initiatives that  Promote quality interactions between plans, providers and other stakeholders  Reduce costs and frustrations associated with healthcare administration  Facilitate administrative healthcare information exchange  Encourage administrative and clinical data integration

Confidential | Copyright © 2014 TriZetto Corporation 5 CORE Overview  CAQH launched the Committee on Operating Rules for Information Exchange (CORE) with the vision of giving providers access to eligibility and benefits information before or at the time of service using the electronic system of their choice for any patient or health plan.  CORE is more than 140 industry stakeholders – health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and other healthcare entities. CORE participants maintain eligibility and benefits data for more than 150 million commercially insured lives plus Medicare and Medicaid beneficiaries.

Confidential | Copyright © 2014 TriZetto Corporation 6 Core Overview – cont.  Working in collaboration they are building consensus on a set of operating rules that will:  Enhance interoperability between providers and payers  Streamline eligibility, benefits, and claim data transactions  Reduce the amount of time and resources providers spend on administrative functions – time better spent with patients.  CORE is tracking and has published metrics regarding rule impact to help quantify participant return on investment.metrics  Operating rules build on existing standards to make electronic transactions more predictable and consistent, regardless of the technology. Rights and responsibilities of all parties, security, transmission standards and formats, response time standards, liabilities, exception processing, error resolution and more must be clearly defined in order to facilitate successful interoperability. Beyond reducing cost and administrative hassles, operating rules foster trust among all participants.

8 CAQH CORE I and II in QicLink™

Confidential | Copyright © 2014 TriZetto Corporation 9 Types of Requests and Transactions Requests/Inquiries  QicLink™  Without HIPAA Gateway  With HIPAA Gateway  Web Service (Real time or Batch)  Without HIPAA Gateway  With HIPAA Gateway Transaction Types covered by the Requests – 5010 only  270/271 - Eligibility  276/277 - Claim  835 Response - Payment

Confidential | Copyright © 2014 TriZetto Corporation 10 QicLink™ Request – simple diagram 270/271 or 276/277 without Gateway Clearing house QicLink QCC Manager/ Processor CAQH CORE DB QCC Manager/ Processor QicLink Repository

Confidential | Copyright © 2014 TriZetto Corporation 22 ETL Processing  SQL script to copy 33 tables from QicLink™  to the CAQH CORE DB.  The ETL data transfer process has two steps.  Step 1 is to export the data from the QicLink database to.dat files using the SQL Server bcp.exe process.  Step 2 is to import each.dat file into the QCCService Database. The export process is run by the usp_CAQH_ExportList stored procedure in the QicLink database and import process is run by the usp_CAQH_ImportList stored procedure in the QCCService database.

Confidential | Copyright © 2014 TriZetto Corporation 23 ETL Processing  34 database tables are copied plus one temporary table that is only used in the ETL and is deleted after it is used.  Each export has 3 files per table plus one more table is created for each table on import. The 4 files are: .dat – this is the data file and only required file. The other 3 are only used if there is an error. .fmt – this is the format file for the data. It is only used for troubleshooting  export_error.log – This is the export error log. It should be blank indicating no errors.  import_error.log – This is the import error log. It should be blank indicating no errors.  There are an additional 105 files for troubleshooting.

Confidential | Copyright © 2014 TriZetto Corporation 24 ETL – cont.  The ETL data transfer process has two steps.  Step 1 is to export the data from the QicLink™ database to.dat files using the SQL Server bcp.exe process.  Step 2 is to import each.dat file into the QCCService Database. The export process is run by the usp_CAQH_ExportList stored procedure in the QicLink database and import process is run by the usp_CAQH_ImportList stored procedure in the QCCService database.

Confidential | Copyright © 2014 TriZetto Corporation 25 ETL File List  miscde  contrl  prvmst  prvadl  prvnpi  ecshdr  ecslin  ecsprv  ecsubf  clmhdr  clmdet  clmdes  clckfl  ecsclm  clmcal  clmubf ltrdet  elgemp  elgdep  elghis  elgadr  elgprv  grpben  pdparm  ppcoip  ppcopa  pppded  ppplan  spdclm  stbtxf  stcnxf  stcpxf  stdcxf  QL835Trans   tempDatabaseID – ETL process only file.

Confidential | Copyright © 2014 TriZetto Corporation 29 270/276 Transactions through QicLink™ Clearinghouse HIPAA Gateway Compliance Check …… C:\ecedigs\PF_PostOff ice\. The specific inbound/outbound folders reside under PF_PostOffice. ……

Confidential | Copyright © 2014 TriZetto Corporation 50 835 Processing  As previously done, run HIP835C  HIP835C will continue to do what it does today for both Gateway and non-Gateway  Update the Transport tables for Gateway a  Update the share drive/database for non-Gateway.  New with CAQH CORE  Whether you are Gateway or Non-Gateway a new table called QL835Tran will also house the transaction data  ETL will be run to take the data from the QL835Tran Table, truncate it (so it won’t be grabbed again) and move it to the CAQH CORE DB.

Confidential | Copyright © 2014 TriZetto Corporation 51 835 Web Call  ETL take records from the local QL835Trans Table and put them in the QL835 Trans Table in the CAQH CORE DB.  Scheduler needs to be invoked to merge transactions into a single Trading Partner Transaction. Marked for Ready  New File name is written to the Repository  Web Request comes through the QCC Manager which checks for the statuses, loads them to the output file and marks then with a “ P” for picked up.

Confidential | Copyright © 2014 TriZetto Corporation 56 Phase III Enhancement Contains Phase III CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule Phase III CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) 835 Rule Phase III CORE 370 EFT & ERA Reassociation (CCD+/835) Rule

Confidential | Copyright © 2014 TriZetto Corporation 58 Workshop Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should have received an e-mail notification for you to take an on-line survey. If you could take a few minutes to complete at this time, we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately.

Confidential | Copyright © 2014 TriZetto Corporation 1.

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